Enhancing Laryngoscopy Mastery: The Impact of Autonomous Practice with Feedback-Providing Simulators.

Mastery learning with fixed end points and variable training time leads to more consistent expertise but is difficult to implement. Here we piloted mastery learning of laryngoscopy with independent practice. 35 learners participated in independent mastery learning on a manikin that provides automated performance feedback. A pre- and postpractice assessment of intubation skills was completed. After an average of 21 minutes of open practice, the percentage of subjects that met mastery criteria improved from 24% to 89% (P < .05). Independent intubation practice with manikin feedback facilitated mastery learning, enhanced procedural education, and may impact clinical care.

Qua-Alluding to the Past: A Case of Methaqualone Analog Ingestion.

Methaqualone, known previously under the brand name Quaalude, is a Schedule I sedative hypnotic drug that may cause neurotoxicity in overdose, characterized by somnolence, hyperreflexia and muscular hyperactivity. We present a case of a 21-year-old male who reportedly ingested methaqualone in addition to insufflation of street cocaine. He subsequently developed hypoxia, hyperreflexia, myoclonus, and altered mental status. His laboratory results were notable for the presence of methemoglobinemia, which was most likely due to a cocaine contaminant. Laboratory analysis of the alleged methaqualone pills identified the substance as SL-164, a dichlorinated methaqualone analog. Urine toxicology results were positive for SL-164 (and presumed metabolites) as well as for cocaine and tetrahydrocannabinol metabolites. The patient was treated with supplemental oxygen and a benzodiazepine (lorazepam) and observed in the Emergency Department (ED) until his symptoms resolved. This case highlights current community access to methaqualone analogs. The case also focuses on laboratory techniques used to identify the methaqualone analog.

Teaching Rapid Assessment Skills in Triage for the Emergency Medicine Clerkship.

BACKGROUND: Rapidly assessing an undifferentiated patient and developing a gestalt for "sick vs. not sick" is a core component of emergency medicine (EM). Developing this skill requires clinical experience and pattern recognition, which can be difficult to attain during a typical EM clerkship. OBJECTIVE: We developed a novel approach to teaching medical students rapid assessment skills in the emergency department (ED) by implementing a teaching shift in triage. METHODS: Fourth-year medical students in our EM clerkship in fall 2019 were scheduled one shift in triage with a dedicated teaching attending. The students evaluated patients under direct supervision, discussed their immediate differential diagnosis, and proposed an initial workup. The attending gave real-time feedback using a standardized direct observation tool. Students completed an electronic pre and post survey (5-point Likert scale) to assess their comfort level in the following areas: performing a rapid triage assessment, determining "sick vs. not sick", performing a focused physical examination, developing a targeted differential diagnosis, and ordering an initial diagnostic workup. RESULTS: Twenty-one students participated in the triage shifts. There was a significant improvement in self-assessed comfort with performing a rapid triage assessment, mean pre 2.76 and post 4.43 (p < 0.0001). There were also significant improvements in the four other survey areas (p < 0.004 or less). CONCLUSIONS: A teaching shift in triage can increase medical students' self-assessed rapid assessment skills for patients in the ED. Benefits to the teaching attending included the opportunity to perform direct observation, give real-time feedback, and identify real-time teaching moments.

Spatial-temporal clusters of pediatric perforated appendicitis in California.

BACKGROUND: Perforated appendicitis is a well-documented child health disparity. Geographic patterns in perforated appendicitis exist in several United States regions, but such patterns have not been described in California. We aimed to analyze spatial-temporal patterns of pediatric perforated appendicitis and identify population characteristics contributing to these cluster patterns. METHODS: We geocoded risk-adjusted perforated appendicitis rates per 1000 appendicitis cases in patients 1-17 years from 2005-2015 in California. We performed a space-time cube analysis to identify hot spot trends. We performed logistic regression to estimate rural classification associated with spatial-temporal hot spots and multivariate analysis to assess effects of socioeconomic factors. RESULTS: In 2005-2015, 43,888 cases of pediatric perforated appendicitis occurred in California. Median risk-adjusted perforated appendicitis rate was 312 per 1000 appendicitis cases. We identified 11 spatial-temporal hot spots of perforated appendicitis. Rural micropolitan counties had 14 times higher odds of being classified as a hot spot (p<0.05, 95% CI 1-185). Poverty was a significant predictor of high perforated appendicitis median risk-adjusted rate (p<0.004). CONCLUSIONS: We identified 11 California hot spots of perforated appendicitis that persisted across a ten-year time span. Incorporating geography alongside our understanding of socioeconomic factors is a critical step in addressing this important child health disparity.